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Pediatr Surg Int (2002) 18: 668672

DOI 10.1007/s00383-002-0770-y

O R I GI N A L A R T IC L E

Jayant Radhakrishnan Asim Razzaq


Kannan Manickam

Concealed penis

Accepted: 13 July 2001 / Published online: 17 September 2002


Springer-Verlag 2002

Abstract A small phallus causes great concern regard-


ing genital adequacy. A concealed penis, although of
Introduction
normal size, appears small either because it is buried in
The penis is inconspicuous if it is absent (penile agene-
prepubic tissues, enclosed in scrotal tissue penis palma-
sis), diminutive (epispadias, hypospadias, chordee), mi-
tus (PP), or trapped due to phimosis or a scar following
cropenis (hypothalamic, pituitary or testicular origin),
circumcision or trauma. From July 1978 to January
or concealed. A penis of normal size may be concealed
2001 we operated upon 92 boys with concealed penises;
because it is (a) buried in prepubic tissues, (b) buried and
49 had buried penises (BP), while PP of varying degrees
also enclosed in scrotal tissue (penis palmatus), (c)
was noted in 14. Of 29 patients with a trapped penis,
trapped secondary to phimosis, post-circumcision cica-
phimosis was noted in 9, post-circumcision cicatrix
trix, or trauma or (d) hidden because of a large hernia or
(PCC) in 17, radical circumcision in 2, and posttrau-
hydrocele.
matic scarring in 1. The BP was corrected at 23 years of
age by incising the inner prepuce circumferentially,
degloving the penis to the penopubic junction, dividing
dysgenetic bands, and suturing the dermis of the pen- Materials and methods
opubic skin to Bucks fascia with nonabsorbable sutures.
Between July 1978 and January 2001, one hundred and forty-three
Patients with PP required displacement of the scrotum in boys were referred to us for evaluation and treatment of a con-
addition to correction of the BP. Phimosis was treated cealed penis (Table 1). In all patients the stretched penile length
by circumcision. Patients with a PCC were recircumcised was appropriate for age. Most of these patients presented as infants
carefully, preserving normal skin, but Z-plasties and but there were boys of all ages with the oldest being 16 years old.
Three patients had a prior failed operation for a buried penis. Two
Byars aps were often required for skin coverage. After boys are extremely obese and we are not willing to operate on them
radical circumcision and trauma, vascularized aps were at this time. In the remaining the degree of obesity was no dierent
raised to cover the defect. Satisfactory results were ob- from that in the population at large. We operated upon ninety-two
tained in all cases although 2 patients with BP required a patients. In all the patients the immediate post operative appear-
ance of the penis was maintained on long term followup. In twenty-
second operation. The operation required to correct a nine of the remaining fty-one, the problem resolved spontaneously
concealed penis has to be tailored to its etiology. while eight are still being followed. Patients with a concealed penis
due to a large hernia or hydrocele are excluded from this report.
Keywords Penis Concealed Trapped Webbed
Penis palmatus Buried penis

Infants presenting with a buried penis were observed until two to


three years of age and operated upon if there was no evidence of
J. Radhakrishnan (&) A. Razzaq K. Manickam improvement. A partially buried penis generally resolved sponta-
Division of Pediatric Surgery, neously as prepubic fat disappeared with elongation of the lower
The University of Illinois, abdomen. Older children were operated upon when rst seen. In all
Chicago, IL, USA but one patient with a buried penis the operation consisted of a
E-mail: jrpds@hotmail.com circumcoronal incision in the inner prepuce 5 mm from the corona.
Fax: +01-815-652-6818 Since 1985, we have also added a vertical ventral incision down
to the base of the penis as described by Redman [1] (Figs. 1 and 2).
J. Radhakrishnan The penis was degloved to the penopubic junction, dysgenetic
The University of Illinois, dartos fascia was divided, and the dermis of the skin at the pen-
1502 71st. Street, opubic junction was sutured to Bucks fascia at the 2 oclock and
Darien, IL 60561, USA 10 oclock positions and dermis at the proposed penoscrotal
669

Table 1 Data of patients with


concealed penis Total no. of patients: 143

A. Operated: 92
1. Buried penis 49 (2 previously operated)
2. Penis palmatus 14
3. Trapped penis 29
a. Phimosis 9
b. Post-circumcision cicatrix 17
c. Radical circumcision 2
d. Trauma 1
B. Concealed penis observed: 51
1. Resolved 29
2. Being observed 8 (2 extreme obesity, 1 previously
operated)
3. Lost to follow-up 9
4. Operated elsewhere 5

junction was sutured to Bucks fascia at the 5 oclock and 7 oclock with a webbed penis, after the circumcoronal incision, an inverted
positions. Penile skin was then wrapped snugly around the penis V-shaped incision was made instead of a ventral midline incision,
and the ventral skin decit was closed. Z-plasties were used when extending downward and outward on either side of the midline
required. On occasion, the dorsal skin ap had to be mobilized in raphe onto the scrotum. Upon closure as an inverted Y, it per-
the prepubic area to permit it to be advanced downward for at- mitted the scrotum to drop downward and created a penoscrotal
tachment to Bucks fascia. One patient was treated with the junction. Doughnut scrotum was corrected by making inverted V-
preputial unfurling technique of Donahoe and Keating [2]. shaped incisions on each side of the penis with the apex of the V at
the root of the scrotum. The incisions were either closed as inverted
Ys (Fig. 3) or the strip of tissue within the V was excised to obtain a
Penis palmatus straight vertical suture line [3].
These patients had inadequate scrotal migration that varied any-
where from a webbed penis to a doughnut scrotum. For patients
Trapped penis

Penises trapped in the scrotum due to pinpoint phimosis were easily


corrected by circumcision. If these patients presented as infants
they were operated upon expeditiously, since they not only do not
improve spontaneously, but the scar tends to tighten further as it
matures. In patients with a post-circumcision cicatrix that closed
over the distal glans like an iris we rst made a vertical ventral
incision in the cicatrix to separate the skin from the glans. Al-
though all scarred skin should be removed, on occasion when the
scarring was extensive, some of the scar had to be shaved from
within to preserve skin length. All these patients required Z-plasties
or Byars aps to obtain adequate ventral skin coverage. The two
patients who had a radical circumcision and one with a post
traumatic scar following a crushed pelvis were reconstructed with
skin aps in the manner previously reported by us [4].

Results

Buried penis

Only one of the patients operated upon by the technique


described had a poor cosmetic result. Upon reoperation,
we found that our sutures had either missed the dermis
or had cut through it. The sutures were noted to be
attaching mobile subcutaneous tissues to Bucks fascia.
Upon replacing the sutures appropriately through the
dermis an excellent result was obtained. Our one expe-
rience with the preputial unfurling technique was un-
Fig. 1 Illustration of buried penis and its correction, A Lateral satisfactory since there was considerable edema and the
view demonstrating lack of attachment of skin to shaft of penis and buried penis recurred. Upon reexploration through the
fat pad anterior to the pubis. B The penis is made visible by previous incision combined with a vertical ventral inci-
displacing prepubic fat. A circumcoronal incision with a ventral sion we were able to divide dysgenetic fascia and reat-
midline vertical extension upto the proposed penoscrotal junction
is marked. C The penis is degloved down to its base and the tach the penopubic dermis to Bucks fascia with
abnormal dartos attachments are divided (black arrow). D adequate protrusion of the penis, however, in this
Completed repair with circumcoronal and ventral midline sutures African-American male, the result is unsatisfactory as
670

Fig. 2 Patient with buried penis. A Completely invisible penis. B


The penis protrudes upon displacement of prepubic fat. C A Discussion
glanular stay suture is used for traction. Proposed line of incision is
marked. D After the circumcoronal incision is made and penis Buried penis was rst described by Keyes in 1919 [5]. In
is degloved it disappears upon release of traction. E Penile skin ap
is developed up to the base of the penis and dysgenetic bands have 1958, Byars and Tries were the rst to identify a trapped
been divided. F Completed reconstruction penis following circumcision [6], and in 1959 Keshin [7]
rst reported a post-traumatic penile dislocation. The
rst attempt at correction of a BP was made by Schloss
skin covering the penis has three dierent shades of in 1959 [8], who carried out an emergent circumcision
color.
Apart from the two instances mentioned above, in all
others, the parents and patients were very pleased with
the results of the operation. Only one of these patients is
sexually active so far and he does not have any com-
plaints.

Penis palmatus

In all patients with PP the BP component was addressed


adequately. Patients with a webbed penis had an excel-
lent result, while those with a doughnut scrotum and a
shawl scrotum have a slight transverse fold of skin at the
base of the penis, which had to be preserved to maintain
blood supply to the skin covering the penis.

Trapped penis

Excellent protrustion was obtained in all patients with a


primary phimosis. Of the patients with a PCC, 1 still
requires retraction of skin to prevent adhesions from Fig. 3 Inverted V-Y plasty for correction of peno-scrotal transpo-
reforming. The 3 patients who required vascularized sition. Point B slides down to convert a V into a Y as demonstrated
aps all had excellent results. in the inset
671

and permitted the raw area proximal to the corona to Hinman [23] and attachment of the penis to the pubic
granulate in by having the mother retract the skin on a periosteum as described by Johnston [27].
daily basis. At the time of the report, 2 years later, It appears that the following elements are required
retraction was still required. In 1968, Glanz [9] success- for successful correction of a BP: (1) degloving of penile
fully corrected a BP in a 57-year-old man by making skin down to the base of the penis; (2) division of dartos
multiple ventral and dorsal Z-plasties on the penis. bands that dislocate the penis; (3) unfurling of penile
The majority of our patients presented when the pe- skin to cover the shaft; (4) suture of the dermis at the
diatrician, parents, or older boys themselves were con- penopubic and penoscrotal junctions to Bucks fascia;
cerned about the size of the penis. In addition, patients (5) snug wrapping of penile skin around the penile shaft;
with a BP who were voiding into the preputial sac were (6) creation of a penoscrotal angle; and (7) Z-plasties for
persistently wet. Balanoposthitis and urinary infections ventral skin closure.
can occur, but did not in our patients [1012]. Older Prior to 1985, we carried out the above procedure
patients also had diculty directing the urinary stream, through a circumcoronal incision only. Division of the
which sprayed, and they were wet after voiding. In the dartos bands and accurate approximation of the pen-
29 patients in whom the problem resolved spontaneously opubic dermis was dicult through this incision and, in
there was no phimosis or post circumcision cicatrix, fact, resulted in 1 failure. Addition of the ventral vertical
their prepubic fat pad was not excessive and there was a component described by Redman [1] not only made the
circumferential groove at the base of the penis. dissection and suturing more precise, but also permitted
Glanz [9] attributed buried and webbed penis to the penile skin to be snugly wrapped around the shaft of
abnormal attachment of skin due to an embryonic carry the penis and to develop a well-dened penoscrotal an-
over of a vestigial cloacal veil whereas Crawford [13] felt gle. Numerous modications of the Redman procedure
that dorsal dysgenetic bromuscular bands caused the have been described [12, 14, 1719, 2834]. Although we
buried penis. We agree with Devine [14] and Cromie [12] believe the suprapubic fat pad adds to the problem, we
who indicate that since these dysgenetic dartos bands do not remove it since it reaccumulates, as occurred in 2
are only attached at the corona the penis retracts and patients who came to us after a prior failed operation
adequate attachment of skin to the shaft of the penis is that involved its removal. We are also reluctant to suture
prevented. Johnston [15] wondered whether these dys- Bucks fascia to the pubic periosteum, since it could
genetic bands were cause or eect. We disagree with cause pain during an erection.
Wollin [16] who states that the defect is ventral rather PP occurs in a wide spectrum. In the webbed penis
than dorsal and with Joseph [17] who blames it on infe- the scrotum creeps up onto the penis, and along with
rior displacement of the root of penis. He believes that fat correction of the BP a penoscrotal junction has to be
and areolar tissue secondarily ll the space created and created by an inverted V-Y-plasty or Z-plasties. At the
he does not believe that the fat pad worsens the situation. other end of the spectrum of inadequate scrotal migra-
In our opinion and that of others [11, 18], a large sup- tion is the doughnut scrotum which results in a toad in
rapubic fat pad does seem to contribute to the problem. the hole penis and the Shawl penis, in which a hor-
Casale [19] attributes the problem to the presence of a izontal skin fold runs dorsally at the base of the penis. In
web, hypermotility of the angle of the penis, a circum- these patients the dorsal conuence of the scrotum is
ferential scar and disproportionate obesity. displaced ventrally by making V-Y plasties on either side
We classied concealed penis on the basis of the type or by rotating scrotal skin aps from the dorsal to the
of operation required to correct it (Table 1). Other ventral aspect in addition to correction of the buried
classications have been proposed by Crawford [13], penis. Care has to be taken to place the apex of each
Hinman [20], Maizels [11] and Bloom [21]. Only Maizels inverted V such that the base of the dorsal skin ap to
[22] and Burkholder [10] have noted an association with the shaft of the penis is as wide as possible and retains its
renal anomalies. Other genito-urinary anomalies are not blood supply.
to associated with the condition. Patients with a trapped penis due to a post circum-
We believe that, in the infant, if the buried penis has cision cicatrix or phimosis essentially require a circum-
not resolved by two to three years of age it will require cision which, in the former instance, should carefully
correction. It is also important that the patient be able to avoid excessive removal of skin.
void standing up when he is toilet trained. Patients with a denuded penis due to a radical
Numerous operative procedures have been described circumcision or after trauma have been treated in
for management of the buried penis. Hinman [23], various ways including use of vascularized aps [4],
Perlmutter [24] and Masih [25] used a two-stage proce- split-thickness skin grafts [35], multiple Z-plasties [9,
dure requiring burial in the scrotum. Hinman also ex- 34] and two-stage repair after burying the penis in the
cised the suprapubic fat pad. Others have used skin aps scrotum. Our personal preference is for vascularized
alone to [2, 9, 16, 26], while Johnston [27] sutured the aps.
penis to the pubic periosteum, Crawford [13] divided In conclusion, a smooth transition from prepubic
only the dysgenetic fascia, and Burkholder and Newell skin to penile skin is indicative of a buried penis. A
[10] placed a short penile prosthesis. Maizels et al. [11] trapped penis can be dierentiated from it by the pres-
combined removal of prepubic fat as described by ence of a circumferential groove at the base of the penis.
672

Neonates with a buried penis should not be circumcised 16. Wollin M, Duy PG, Malone PS, et al (1990) Buried penis. A
at birth. novel approach. Brit J Urol 65: 97100
17. Joseph VT (1995) A new approach to the surgical correction of
buried penis. J Pediatr Surg 30: 727729
Acknowledgements The authors wish to thank Dr. Russell Pearl 18. Horton CE, Vorstman B, Teasley D, et al (1987) Hidden penis
for his illustrations. release: adjunctive suprapubic lipectomy. Ann Plastic Surg 19:
131134
19. Casale AJ, Beck SD, Cain MP, et al (1998) Concealed penis in
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